MSE – Flashcard
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the MSE is to psychiatric nursing as
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the physical exam is to medical nursing
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MSE
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represents a cross section of the patient's psychological life and the nurse's observations and impressions at one point in time
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elements of the examination depend on,,
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the pt's clinical presentation as well as patient's educational and sociocultural background
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the MSE is an evaluation of the patient's
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current state
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how is information recorded?
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specific and objective, not global or judgmental
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Content
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overtly communicated information
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Process
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how the communication occurs and includes feelings, intuition and behaviors that accompany speech and thought
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what can greatly influence the outcome of the examination?
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sociocultural factors
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Observations
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- apparent age - manner of dress - cleanliness - posture - gait - facial expressions - eye contact - pupil dilation or constriction - general state of health and nutrition
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Speech observations
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- rate - volume - amount - characteristics
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manic patients usually wear
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colorful or unusual attires and have pressured speech
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stooped posture may indicate
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depression
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drug or narcotic indicaions
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dilated pupils or pupil contriction
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Motor activity
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- level of activity: lethargic, tense, restless - type of activity: tics, grimaces or tremors - unusual gesture or mannerisms: compulsive behavior
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Mood
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pt's self-report of one's emotional state and reflect the pt's life situation
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if the potential for suicide is suspected, the nurse should
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ask the pt directly about thoughts of self harm
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to judge a patient's suicidal or homicidal risk, the nurse should asess
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the patient's plans and ability to carry out those plans. The patient's attitude about death and support systems abilable to the pt
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Affect
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the patient's apparent emotional tone. The pt's statementsof emotions and nurse's empathic responses provide clues to the appropriateness of the affect
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flat affect
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absence of emotional expression as seen in a pt who reports sig. life events without showing any emotional response; usually seen in schizophrenia
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lability
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undergoing frequent changes from one affective response (sadness) to another (happiness) quickly in the same conversation; usually seen in mania
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Hallucinations
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false sensory impressions or experiences - auditory - visual - tactile (touch) - gustatory (taste) - olfactory (smell)
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Illusions
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false perceptions or false responses to sensory stimulus
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Command hallucinations
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those that tell the patient to do something ex. kill themselves or harm another orjoing someone in the afterlife
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dif types of hallucinations may indicate
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visual: schizophrenia visual: organic mental D/O tactile: organic mental D/O, cocaine abuse, delirium tremens
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Thought content
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specific meaning expressed in pt's communication. It refers to the "what" of the pt's thinking
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in obtaining the thought content, it is important for the RN to..
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obtain info about the pt's thinking and not challenge or try to correct the pt's beliefs
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Thought process
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"how" the pt's self-expression. It is observed through speech
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Thought process indications
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Circumstantial: defensiveness or paranoid thinking Loose associations/neogisms: schizophrenia or psychotic D/O Flight of ideas: mania Perseveration: brain damage or psychotic D/O Word salad: highest level of tough disorganizaton
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LOC
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pt's orientation tothe current situation - confused, sedated, stuporous - time, place, person
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LOC implications
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oranica mental D/O= grossly inaccurate answers Schizophrenic= another person
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Memory
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ability to recall past experiences Remote: distant past Recent: past week or so Immediate memory: just exposed
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confaculation
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when pt makes up stores about situations or events that can't be remembered
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Level of concentration and calculation
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Pt's ability to pay attention during the course of the interview calculation: ability to do simple math ex. count from 1-20 rapidly
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the nurse should be cautious about judging intelligence, after
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a frief and lmited contact typical of the time it takes to conduct a MSE
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emotional intelligence has 4 elements
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1. self-awareness 2. self-management 3. social awareness 4. social skills
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Judgement
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involves making decisions that are constructive and adaptive. It involves the ability to understand facts and draw conclusions from relationships
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Insight
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patient's understanding of the nature of one's problem or illness
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moticational interviewing
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can asses the pt's readiness to change
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Mini MSE
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a simplified, scored form of the cognitive MSE
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intelligence tests
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1. WAIS, Wechsler Adults intelligence scales 2. WISC, Wechsler Intelligence Scale for CHildren
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Projective tests
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reflect aspects of a person's personality, including reality testing ability, impulse control , ego defenses, interpersonal conflicts and self-concept
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Behavioral rating scales and measurement tools help clinicians to...
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1. measure extent of pt's prob 2. make accurate Dx 3. track pt's progress 4. doc efficacy of treatment
